Streamlining the assessment of haematuria: 3-year outcomes of a dedicated haematuria clinic.

BACKGROUND: Urgent assessment of haematuria is critical to exclude malignancy. The objective of this study is to report the outcomes of the first 3 years of a dedicated haematuria clinic at the Royal Melbourne Hospital, a Victorian tertiary hospital. METHODS: All patients assessed in the haematuria clinic from April 2010 to April 2013 were included in the analysis. Outcomes were recorded prospectively and analysed retrospectively. RESULTS: A total of 643 patients were seen in the haematuria clinic with non-visible (170, 26%) and visible haematuria (463, 72%) during this time period, all within 28 days of referral being triaged. Sixty-five (10%) patients were diagnosed with urothelial carcinoma, 63 with lower tract disease and two with upper tract urothelial carcinoma and another five (1%) patients with other tumours. Thirty out of 63 (48%) of the bladder urothelial carcinomas were invasive or high-grade. Two hundred and sixty-seven (42%) patients were discharged from the clinic after a single point of contact. One hundred and fifty-three (24%) patients were referred for further definitive management of suspected pathology. Two hundred and twenty-three (34%) patients were referred to outpatients clinic for further investigations. Urothelial carcinoma was diagnosed more often in males, older patients and patients with visible haematuria. CONCLUSION: The Royal Melbourne Hospital haematuria clinic has served as an effective tool for rapid, streamlined assessment of patients presenting with haematuria. Follow-up of investigations by nurses and moving towards a 'one-stop' approach are helping to further decrease the number of patients requiring a second clinic visit.

Nurse-led flexible cystoscopy in Australia: initial experience and early results.

OBJECTIVE: • To present our initial experience implementing a nurse-led flexible cystoscopy (NLFC) service in a Victorian tertiary hospital and our initial results from that service, as NLFC has developed over the past decade with reports suggesting that adequately trained nurses can undertake FC competently. PATIENTS AND METHODS: • We describe the implementation of a NLFC service including approval, funding, nurses' training, and protocols. • Outcomes of all patients having a NLFC or subsequent interventions were recorded prospectively and analysed retrospectively. • To gauge patients' response to NLFC, an anonymous feedback questionnaire was administered to 60 consecutive participating patients in the recovery unit. • The effect of NLFC on waiting times was determined from surgical scheduling records. RESULTS: • In all, 272 patients had 720 NLFC done over a 2-year period. In all, 150 (21%) FCs had a suspected bladder cancer recurrence and were referred for a rigid cystoscopy. Of those, 83 (58%) revealed a recurrence comprising of 14 (17%) high-grade lesions, 45 (54%) low-grade lesions and 24 (29%) were diathermied without a biopsy. In all, 41 (27%) had benign pathology on biopsy and 21 (14%) had normal rigid cystoscopy. • There were two significant adverse events. • There was a 65% reduction in the waiting list for surveillance FC after introduction of the service. • Of 60 patients who completed the feedback questionnaire, 95% reported that they were given enough information by the nurses, 92% had all their questions answered satisfactorily and 97% had enough confidence and trust in the nurse. In all, 90% had a positive perception of the service overall and 93% were happy to have a FC performed by a nurse rather than a doctor. CONCLUSIONS: • Results from our NLFC audit compare favourably with other published reports. NLFC is a safe and feasible option when established alongside strong departmental support, comprehensive nurses' training according to established guidelines, service supervision by a designated consultant and regular audits. • NLFC clinics can provide an efficient service and excellent continuity of care for patients with non-muscle-invasive bladder cancer.

A randomized trial of photoselective vaporization of the prostate using the 80-W potassium-titanyl-phosphate laser vs transurethral prostatectomy, with a 1-year follow-up.

OBJECTIVE: To compare the potassium-titanyl-phosphate Greenlight(TM) 80-W laser ablation system for photovaporization of the prostate (PVP; Laserscope, San Jose, CA, USA) with transurethral resection of the prostate (TURP), as many technologies have been proposed as equivalent or superior to TURP without gaining widespread acceptance, due to lack of data from randomized trials. PATIENTS AND METHODS: In all, 120 patients were randomized to undergo either TURP or PVP after a full urological evaluation, which was repeated at 1, 3, 6 and 12 months after surgery. Irrigation use, duration of catheterization (DOC), length of hospital stay (LOS), blood loss, cost and operative time were also assessed. RESULTS: Both groups showed a significant increase in mean (sd) maximum urinary flow rate from baseline (P < 0.05); in the TURP group from 8.9 (3.0) to 19.4 (8.7) mL/s (154%), and in the PVP group from 8.8 (2.5) to 18.6 (8.2) mL/s (136%). The International Prostate Symptom Score (IPSS) decreased from 25.4 (5.7) to 10.9 (9.4) in the TURP group (53%), and from 25.3 (5.9) to 8.9 (7.6) in the PVP group (61%). The trends were similar for the bother and Quality of Life scores. There was no difference in sexual function as measured by Baseline Sexual Function Questionnaires. The DOC was significantly less in the PVP than the TURP group (P < 0.001), with a mean (range) of 13 (0-24) h vs 44.7 (6-192) h. The situation was similar for LOS (P < 0.001), with a mean (range) of 1.09 (1-2) and 3.6 (3-9) days in the PVP and TURP groups, respectively. Adverse events and complications were less frequent in the PVP group. Costs were also 22% less in the PVP group. CONCLUSIONS: This trial shows that PVP is an effective technique when compared to TURP, producing equivalent improvements in flow rates and IPSS with the advantages of markedly reduced LOS, DOC and adverse events. A long-term follow-up is being undertaken to ensure durability of these results.

KTP laser versus transurethral resection: early results of a randomized trial.

BACKGROUND AND PURPOSE: Many technologies have been mooted as equal to transurethral resection of the prostate (TURP) without gaining widespread acceptance because of the lack of randomized trials. The Greenlight laser system (Laserscope, San Jose, Ca.), an 80 W system for photovaporization of the prostate (PVP), was compared with TURP in such a trial. PATIENTS AND METHODS: A series of 120 patients was randomized to undergo TURP or PVP after evaluation, which was repeated at 1, 3, 6, and 12 months after treatment. Irrigation use, length of catherization (LOC), length of hospital stay (LOS), postvoiding residual volume, sexual function, blood loss, cost, and operative time also were assessed. RESULTS: To date, 76 patients are evaluable. Both groups showed a significant (P < 0.5) increase in maximum flow rate from baseline. In the TURP group, flow increased from 8.7 to 17.9 mL/sec (149%) and in the PVP group from 8.5 to 20.6 mL/sec (167%). The International Prostate Symptom Score decreased from 25.4 to 12.4(50.23%) in the TURP group and from 25.7 to 12.0 (49.83%) in the PVP group. Postvoiding residual volumes also showed significant decreases. Similar trends were seen in relation to bother and quality of life scores. There was no difference in sexual function as measured by a questionnaire. The LOC was significantly less in the PVP group (P < 0.001), the mean being 12.2 hours (range 0-24 hours) versus 44.5 hours for TURP (range 6-192 hours). A similar situation was seen in relation to LOS (P < 0.0001), with the mean of the PVP group being 1.08 days (range 1-2 days) and the mean for the TURP group being 3.4 days (range 3-9 days). Adverse events were less frequent in the PVP group, and the costs were 22% less. CONCLUSIONS: This trial demonstrates that PVP is effective compared with TURP, producing equivalent improvements in flow rates and IPSS with markedly reduced LOS, LOC, and adverse events. Long-term follow- up is being undertaken to assess the durability of these results.